As one of its last acts of 2016, Congress could drop about $1 billion on America’s drug problem by approving the 21st Century Cures Act. The bipartisan bill, which includes funds to help states combat opioid addiction and overdoses, is up for final approval in the Senate, and President Obama wants to sign it into law before he leaves office.
But even if the legislation is approved as expected, Obama won’t be around to decide exactly how the money is spent. That responsibility falls to President-elect Donald Trump and the conservative ex-surgeon from Georgia he picked to lead the Department of Health and Human Services, Rep. Tom Price. Trump and Price have both vowed loudly and repeatedly to repeal the Affordable Care Act, widely known as Obamacare, which some experts feel would worsen an already dire crisis.
Trump hasn’t offered many specifics about how he’ll tackle the opioid epidemic and the 78 fatal overdoses per day that come with it. The situation is especially bad in many of his stronghold states, but he gave only one speech about the issue on the campaign trail. His remarks largely focused on reducing the supply of drugs — a strategy that has failed the U.S. for decades — but he also pledged to “dramatically expand access to treatment slots and end Medicaid policies that obstruct inpatient treatment.”
At the same time, however, Trump and Price want to repeal Obamacare which gave 1.2 million people in 31 states access to addiction treatment under its expansion of Medicaid. At least another least 1.1 million people with substance abuse disorders live in states that declined to opt-in to Obamacare’s Medicaid expansion. Obamacare also made substance abuse coverage an essential health benefit, requiring insurers to pay for the services.
Price, a Tea Party Republican from the Atlanta suburbs, has proposed a replacement to Obamacare, but it would not require insurers to cover addiction treatment. Both he and Trump also want to give states greater control over Medicaid spending, an approach that raises concern among some public health experts.
“Health insurers have even more sway on a state level than the federal level, and the likelihood that they’ll mandate things that are beneficial to people is low,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University School of Law. “Taking mandates away and decreasing regulation will make it harder to ensure that people can get appropriate care for their substance use issues.”
Even with increased coverage since 2010, only one in five opioid addicts receive treatment, according a recent landmark report on addiction by the Surgeon General. The report strongly urged the expansion of medically-assisted treatment programs that use drugs like methadone and Suboxone. Local health officials from 11 major cities have already urged the Trump administration to increase access to these treatments, and “ensure that addiction is addressed as the disease that it is.”
The current lack of access to treatment is partly the result of conservative states refusing to embrace medically-assisted therapies, even though the methods have been proven effective, because they’re sometimes viewed as swapping one addictive substance for another.
Price’s home state of Georgia, for instance, recently placed a moratorium on opening new substance abuse centers that use medically-assisted treatment. The move came despite the fact that overdose deaths are up 10 percent in Georgia, with more than 1,200 fatalities reported in 2014, the most recent year that data is available. The situation is worse elsewhere: Florida, which has twice the population of Georgia, has only 69 treatment centers, one fewer than its northern neighbor. Tennessee has just 14 for the entire state.
The federal government — specifically the Substance Abuse and Mental Health Services Administration, which Price will soon oversee — can push for the expansion of medically-assisted treatment. It’s unclear whether that will be on the agenda though, and states will have wiggle room regardless, since they are responsible for licensing clinics.
Price will also likely push to privatize public health as much as possible, according to Charles Bullock, an expert on Southern politics at the University of Georgia. “Whatever he comes up with in regard to opioid addiction, it’s going to have more a market-oriented approach than you’d get under the Obama administration or any other administration,” Bullock said.
The concern, the political science professor added, is that drug addicts are risky and expensive to cover, making insurers reluctant. With the repeal of Obamacare, insurers would be able to deny coverage for pre-existing conditions, like substance abuse, which would make finding help harder and more expensive for addicts.
“It would be much more the individual shopping in the market and seeing what’s offered, rather than a guarantee that your provider ensures you have access,” Bullock said. “It might be that treatment is available but at a price they can’t afford, particularly if their drug abuse problems are such that they’re not earning much.”
Even funding to alleviate the opioid crisis will be a question mark under Trump and Price. The $1 billion set aside by the impending 21st Century Cures Act is supposed to bankroll initiatives included in another bill, the Comprehensive Addiction and Recovery Act, a sweeping response to the opioid crisis that Congress passed in July — but failed to fund. Critics of 21st Century Cures Act, such as Massachusetts Sen. Elizabeth Warren, who worries that the bill’s provision for yearly reauthorization won’t hold up in a Republican-controlled Congress.
“This final deal has only a tiny fig leaf of funding for NIH and for the opioid crisis,” Warren said. “And most of that fig leaf isn’t even real. Most of the money won’t be there, unless future Congresses pass future bills in future years to fund those dollars.”
While Trump has expressed support for the Comprehensive Addiction and Recovery Act, Price is a hardline deficit hawk who may seek to cut public spending and push people to the private sector to get treatment. And with no guarantee of substance abuse coverage after the expected repeal of Obamacare, experts like Beletsky are concerned for the future.
“Even with the Affordable Care Act, we’ve done too little to get quality prevention and quality treatment, but it’s certainly positive and there’s promising trends,” he said. “Dismantling that system and replacing it with something that’s less robust is something that will almost certainly fuel the opioid crisis.”